Resident education has traditionally devoted itself to knowledge acquisition rather than defined levels of clinical competence. Currently, inexperienced physicians are trained to perform invasive procedures such as central venous catheter (CVC) insertion according to the bedside, apprenticeship model, gaining expertise on real patients in neither a rigorous nor standardized manner. Simulators may ease trainees' transition to actual patients and avoid adverse events. The proposed project aims to investigate the efficacy of a structured simulation training protocol in ultrasound guided CVC insertion for resident physicians. The specific aims are to compare: (1) the failure rate of CVC insertion, and (2) the number of attempts at venous cannulation, rates of technical errors and complications of CVC insertion, and time to CVC insertion on actual patients between residents who have completed a structured, hands-on simulation training protocol (intervention group) and those who are trained according to the traditional, bedside apprenticeship model (control group). We hypothesize that the intervention group will obtain superior skills at CVC insertion on actual patients as compared to the control group as measured by: (1) a reduced failure rate at CVC insertion, (2) a) a reduced number of attempts at venous cannulation b) a decreased rate of technical errors and complications and c) a decreased time to insertion based on an independent rater's evaluation using a procedure checklist. This prospective, randomized observational study will include 1st and 2nd postgraduate year residents over a 21 month period at a tertiary care teaching hospital who rotate through the Emergency Department, Medical Intensive Care Unit and/or Surgical Intensive Care Unit. The intervention group will complete a hands-on ultrasound guided simulation training protocol on a partial task training simulator until competence is achieved as measured by (1) knowledge - a score of > 90% on a written post-training exam, (2) performance - a) the ability to cannulate a simulated vein under ultrasound guidance on first pass in 4/5 consecutive attempts, and b) correct insertion of a CVC on a partial task training simulator with no technical errors as observed by an independent rater. The potential long-term benefit of this research project is the establishment of a structured simulation training protocol for ultrasound guided CVC insertion by resident physicians which will improve patient safety and be applicable to teaching hospitals at a national level. [unreadable] [unreadable] [unreadable] [unreadable]